Acts of care: applied drama, ‘sympathetic presence’ and person-centred nursing

Nursing is the largest healthcare profession, at the forefront of care delivery. The practices and principles of Nursing are associated with kindness, respect and compassion, empowering those in their care and supporting autonomous decision-making (Nursing and Midwifery Council 2016). Nursing pedagogy promotes these attributes as necessary for therapeutic practice (McCormack and McCance 2016). Such values resonate with a relational ‘ethics of care’, as described by Noddings (2013) and Held (2005). However, Nurses can struggle to maintain these qualities in the workplace, in the context of ‘mechanistic’ paradigms of care (De Zulueta 2013), inadequate staffing levels and challenges to patient safety (Louch et al 2016). Emotional exhaustion, diminishing resources and a prioritization of technology can reduce levels of empathy in clinical practice (Digby et al. 2016). Nurses can develop an aversion to ‘positive risk’ within the nurse-patient relationship (Downes et al. 2016).

Following critical reports on the National Health Service (NHS) in the UK, there has been a drive to create a culture of care that delivers a dignified patient experience (O’Neill 2013). Models such as Person-Centred Nursing (PCN) have emerged as frameworks for improvement (McCormack and McCance 2016). One key feature of PCN is the concept of ‘sympathetic presence’, whereby a nurse actively responds to the physical and emotional state of a patient ‘in the moment’ (McCormack and McCance 2016). This concept represents a critique of the limitations of empathy, suggesting that it is neither desirable nor possible ‘to fully comprehend another individual’s particular experience’ (McCormack and McCance 2016). However, the challenge is to develop ‘sympathetic presence’ from a general principle into a set of transferable skills.

Since 2013, students and staff of Nursing and Drama degree programmes at Ulster University (UU) have been collaborating on an interdisciplinary pedagogical project, using drama techniques to enhance engagement with ‘role play’ for clinical training and assessment. Mental Health and Adult Nursing students explore ‘applied drama’ approaches, such as Image Theatre and Forum Theatre (Boal 1998), as well as elements of the Method of Physical Action developed by Constantin Stanislavski for the training and direction of professional actors (Benedetti 1998). Terms and techniques drawn from Stanislavski’s approach, such as ‘actions’ and ‘objectives’, help to develop conscious agency within role play scenarios (drawn from ‘real world’ encounters involving risk management with patients). As part of their assessment, Nursing students provide a critical reflection on the experience, using a framework derived from Asadoorian et al (2011). The evidence suggests that Nursing students have advanced their self-awareness, confidence and communication skills during and after the role plays, demonstrating an improved understanding of ‘sympathetic presence’ and its value within the nurse-patient relationship.

This chapter will examine the potential to understand ‘Person-Centred Nursing’ as a set of performative practices based on attention and intention, a ‘performance of care’ that can be taught, rehearsed and put into action. This understanding derives from a focus on ‘caring’ as a transitive verb, a specific relational act (e.g. ‘I care for you’), as against an abstract noun or adjective (e.g. ‘I am a caring person’).